Provider Demographics
NPI:1275861858
Name:WILSON, DEANNA MARIE (LMT LICENSE #13180)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT LICENSE #13180
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:MARIE
Other - Last Name:MASSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT LICENSE # 13180
Mailing Address - Street 1:7817 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2339
Mailing Address - Country:US
Mailing Address - Phone:503-956-8984
Mailing Address - Fax:
Practice Address - Street 1:7817 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-2339
Practice Address - Country:US
Practice Address - Phone:503-956-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13180225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist